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The Joint Commission (JC) requires the Factors that Affect Learning must be assessed for a hospital or hospital owned physician practice as well as other health care facilities. When assessing this element what does this include? A. The patient's ability to read, method of learning and understan...

What elements must be in a medical record - Answer- Patient ID, Assignment of Benefits, medical history, immunizations, physical exam, lab report, clinical impression, physician orders What is the minimum signature assignment of the author of entry in the medical record? - Answer- First initial, ...

What is the importance of audit in a practice? - Answer- 1. Reviewing quality of care provided to patients. 2. Educating providers on documentation. 3. Ensuring all services are supported and all appropriate revenue is captured. 4. Defending against external audit malpractice litigation and health p...

Informed consent for treatment includes - Answer- a. Patient's diagnosis if known b. Nature and purpose of treatment c. Risks and benefits of treatment d. Alternative treatment options and their benefits and e. e. Risks and benefits of not receiving any treatment The FCA allows for reduced pe...

The Joint Commission requires that Factors that Affect Learning must be ascertained for a hospital or hospital owned physician practice when assessing this element what does this include? - Answer- *The patients ability to read, method learning, & understanding. *Any language or physical disabiliti...

The first initial, last name and credentials - Answer- What is the minimum signature assignment(s) of the author of an entry in the medical record? Personal biographical data and consent for treatment or authorization for treatment form - Answer- Based on Joint Commission accreditation guidance f...

Fraud or Abuse: Billing for a service at a higher level than provided - Answer- Fraud What is a Qua Tam relator? - Answer- A person who brings a civil action for a violation for him/herself & for US Govt What is the difference between Stark Law & Antikickback law? - Answer- No INTENT must be p...

HIPAA was made into law in what year? a. 1992 b. 1994 c. 1996 d. 1998 - Answer- c. August 21, 1996 What standard addresses the use and disclosure of individuals' health information—called "protected health information" or PHI. a. Security Rule b. HIPAA c. Privacy Rule d. minimum ...

B. If documentation supports the service, have the staff contact the carrier to reprocess the claims. Code 33010 was valid for the date of service billed. Rationale: The effective dates of codes are date of service driven. New CPT® codes become effective January 1st of every year. When auditing, v...

When non-compliance is identified, what does the OIG recommended? a .Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. b. Take disciplinary action and document the date ...